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Dr. Hagan, please help.

Dear Dr. Hagan,

I have been reading your posts and hoping you can help me. I had a vitrectomy 6 weeks ago on my OS eye for severe PVD floaters. I was unable to drive or see well out of the eye. 25g, with Kenalog and an air bubble. The surgeon said everything went great, no issues. Immediately after the surgery, I noticed slight distortion in straight lines and my eye feels off. The muscles feel stiffer and like I’m looking through a prescription that is too strong. Everyone said it was the air bubble and not to worry. At my 1 day post op appointment, my pressure was a 5; I became anxious because I had previously read about hypotony maculopathy. The retina doc said the pressure was expected, she examined my dilated eye and it was “normal.” No leaks, she stained the eye to check, etc. she sent me home and I started my drops. The air bubble dissipated after six days but the distortions remained.

My acuity is fine but I am overdue for an exam; OD 20/20, 20/30 OS. I have been very distraught and went to Mass Eye and Ear ER five days after surgery, where my exam and OCT scan were normal. The pressure was at 14. The doctor sat with me and explained the imaging. No wrinkles, edema, swelling, pucker. Again, this doctor told me there was no maculopathy. My surgeon examined me two weeks ago and took another OCT of both eyes; carefully reviewed each scan, scrolled through the entire retina, and compared my left eye to a scan taken before surgery. There is no retinal change. He said my lens has trace peripheral changes possibly due to the air bubble used, but he said he wouldn’t even grade it a 1. He strongly feels it’s a refraction issue, that perhaps my astigmatism increased, and I have an eye exam on Monday. I’ve had this eye my whole life and never experienced distortion.  I have read a simple vitrectomy should not change your prescription.

I’m very disoriented wearing my contact lenses, but much less so when wearing glasses or nothing at all. I’m a 44 yo high myope; at my last exam in 2019 I was -11 with .75 astigmatism in the left (operated) eye. I stayed under at -10.50 to avoid reading glasses but my spectacle prescription is -11.50 with the cylinder for astigmatism. I never wear them except while recovering from the surgery, but while I did, I did not feel this level of disorientation that I do in my contacts which are under corrected. At times it almost feels like the eye muscles are struggling.

The distortions have remained stable; an Amsler grid vertically shows lines ever so slightly undulating and ghosting, horizontally a tiny blip appears then flattens; I’ll blink and it will reappear wherever I look again. It then flattens out again and sort of rumbles along the line. Almost like a heart monitor going flatline. A pinhole test improves the distortions but the little blip will still occasionally appear as I move my eye around.

Here is my OCT scan - top image is from December pre surgery, bottom is a few weeks ago. I apologize for the quality, I took a screenshot with my phone at the appointment.


If you have any ideas what could be causing this, I would greatly appreciate it. I have been sick from worry and anxiety for weeks. The only theory I have is that somehow it’s connected to the transient low pressure but I have no evidence to confirm. My eye still has some pain and redness which seems connected to wearing my contact lenses. I have not had a visual field test, but I don’t seem to have any other visual issues, blind spots etc.

Thank you for reading.
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233488 tn?1310693103
1. at 44 it doesn't take much, an illness, an operation, a personal trauma (death in family, divorce) to suddenly have near problems. I see it all the time.  Someone 43, 44, 45 getting along with out reading glasses or bifocals had a hernia operation and after the surgery can't focus at near. They want to blame the surgeon or anesthesiologist. It's middle age.
2. That was then, this is now. You have had a MAJOR surgery on your eye.   Get a careful glasses refraction in a bifocal form (ideally lineless).  I suspect you will see fine with them once you adjust how to use them.
3. Sounds to me like he was talking about the lens in your eye, not the lens in your glasses.  
4. Your contacts don't have a correction for astigmatism, which you need.  Get the glasses and see if that takes care of it. If it does you will need to switch to toric contacts.   You have had 2 excellent opinions about your eye health.  I believe all three (me and those 2 think this is refractive)
Helpful - 0
Thanks, Dr. Hagan. My appointment is tomorrow, so I’m going to try my best to enjoy today’s weather and keep calm. If you wouldn’t mind my returning with an update, I’d surely appreciate it.
Sure an update will be helpful for people reading this discussion
Hi Dr. Hagan,

I had my refractive appointment today. The optometrist could not explain the reason for my distortions nor could she correct them during the exam. She said my astigmatism has not changed from -75 in the left operated eye. My right eye has actually gone down to -10 from 10.50D which she said is common with advancing presbyopia. My left operated eye has only slightly increased by about .50D.

She did not dilate my eyes (which disappointed me but I was dilated about three weeks ago by my retinal surgeon) however, she did use the microscope to look at my lens; she said the center is totally clear and she could she the peripheries slightly with nothing of concern to note. She is having trouble concluding what is causing the distortion; she said most of her cataract patients, even the cortical ones at their worst, complain of hazy, blurred vision with glare or halos, not “blip” distortions. She said the inside of my eye is very clear, no floaters.

She’s going to “play around” with my contact lens prescription, having ordered multiple trials - she ordered a contact lens for astigmatism as well. She said the “off” feeling I’m having could be due to the new liquid in my eye, and having to get used to it. But that she will try and get me more comfortable visually. My eyeglasses prescription, according to the optometrist, has only worsened slightly and she said she could certainly order me new ones, but it was a mild increase so it’s up to me. She didn’t really address the presbyopia, except to say I’ll likely see a little better up close in my right eye with the change to -10D. She didn’t suggest getting bifocals in my new glasses.

I don’t know, Dr. Hagan. She certainly spent ample time with me, well over an hour, but I was left with no answers. She was honestly stumped. She suggested possibly going to Mass Eye and Ear for testing to see if it’s my brain somehow misinterpreting signals. I’m no doctor, but that doesn’t feel “it” to me.

Do you think I should just go straight to Mass Eye and Ear for a second opinion and/or further testing? I’m back to the haunting feeling this is actually something insidiously retinal.

Thanks for reading.
You can move up to a 'next level' testing which would be a fluorescein angiography. In some instances it shows things not apparent on macular OCT.  I think for your peace of mine you likely need to do this.  
Okay. If it comes back normal does it definitively rule out the macula and/or retina?
Yes.  Your OCT looks normal. Everyone that has seen your eye says it looks normal. You are getting a second opinion from one of the finest eye institutes in the world.
Hi Dr. Hagan,

While I await my appointment at Mass Eye and Ear, my retinal surgeon had me come in for another DFE and OCT. I realized the OCT image I previously sent to you was of the wrong eye, I’m very sorry. I’m sending you the correct (left) eye because I would like your opinion as to whether you find the bright spot on the fovea worrisome, and whether the left side of the scan shows mild wrinkling in the bottom layers, or if it appears normal. I’m including pre-surgery in December for comparison.

4/2/21 Post Surgery

12/4/2021 Pre Surgery

My surgeon noted “peripheral lens changes” in March which have now resolved. He says it was feathering from the air bubble used. I have trace NS in both eyes which existed before surgery. Exam was normal, no inflammation noted anteriorly or posteriorly

Some interesting takeaways from the second refraction:

Pinhole occluder negates the distortions.

The astigmatism toric lens she ordered did not improve the distortions. Or my vision.

Blurring me down to 10.0 from 10.50 in both eyes improves the dizziness and disorientation. It’s not perfect by a long shot but it’s more comfortable than 10.50.

What really struck me is that I’m less dizzy with a weaker prescription in the operated eye even though it refracts at -11. I had to go blurrier in both eyes because they just couldn’t tolerate the half diopter difference. I’m wondering if this gives you any theories as to where the symptoms could be originating from (front of eye/back of eye.)

Thanks for reading.
I am not going to interpret the OCT other than to say the 'slice' (raster line) looks good. To interpret an OCT takes the resolution of a high quality monitor and multiple sections across the macula and different test functions of the OCT computer.  I told you that at your age 44 presbyopia is a big problem and that you would need reading glasses/bifocals. The 'weaker' RX reduces distance vision but helps your middle age focus problem.  I have added about all I can.  Hopefully your exam at Mass EE will provide additional insights.
Hi Dr Hagan,

It has been some time since I last wrote, so I thought I would provide an update. I continue to have dizziness and disorientation in my left operated eye (vitrectomy for floaters.) As part of the diagnostic process, I was seen by a strabismus doctor who dx’d me with mild esotropia made worse on lateral gaze and gave me a 4 diopter prism film to wear on plastic glasses over my contact lenses. Everyone was hopeful this was the answer, but unfortunately it did not relieve my symptoms. It helped with the double vision (which I never noticed until after the vitrectomy) but. I thing else. I asked if the surgery could have caused it but they said unlikely due to both eyes turning inward on lateral gaze.

I received testing at the Cornea department at Mass Eye and Ear. I had a Pentacam scan with lens densitometry. I am told this is refractive testing usually done on cataract patients. Two abnormalities were found in the results; irregular astigmatism inferiorly on the cornea and a lens abnormality on the anterior side of the lens capsule. My retina surgeon said it was a non specific finding, but said it corroborates his suspicion that my symptoms were coming from the lens.

I went to a speciality optometry refraction exam, and was given a comprehensive refraction which revealed the presence of lenticular astigmatism; apparently after being fit with RGPs the “blips” I had been seeing on horizontal lines were improved (external) but the Amsler grid remained vertically ghosted (internal problem.)

Next, my retinal surgeon gave me a trial of 1% Pilocarpine since I noticed my dizziness seemed to be affected by the size of my pupil( the bigger the pupil the dizziness I got. I also developed light sensitivity - it’s painful to the eye and surrounding orbit and oddly causes me to sneeze. The Pilocarpine has helped reduce the dizziness more than anything else. It is a difficult drug to tolerate, but it allows me to feel less debilitated by the dizziness symptoms. The surgeon says my response to the Pilo additionally supports a lenticular cause for my symptoms. I asked him if it could possibly be an occult retinal abnormality (I continue to worry about this because the symptoms are so dramatic) and he said some things that I found interesting (and curious if you agree.) 1) Light sensitivity is not caused by the retina, unless the retina is causing inflammation in the eye. So it is either caused by inflammation or by light being diffracted/refracted abnormally in the lens. 2) Pilocarpine does not attenuate  retinal issues. So he said the fact that my symptoms are improved with using it tells him it’s not the retina.

So, it appears there is a lens abnormality (with possibly a smaller corneal component) that is causing my symptoms. The retina surgeon said I’m a bit of an outlier because the symptoms are dramatic, but there is now likely an irregularity in the lens of some kind, which is throwing my brain off. This is also likely the source of the blips I am seeing, though it could still be from the cornea.

The next step is to try and blur me down in the operated eye, starting with +1.5 diopter difference, possibly going to +3.5 difference if I can tolerate it. He and the optometrist are hoping it will blur enough to stop the dizziness. The step after that would be a custom astigmatic RGP. The next step after that would probably be lens replacement. I don’t know.

It has been a long and difficult road. I still have fears we are chasing the wrong rabbit, especially when I’m told my symptoms are atypical. I don’t know why this ha caused me such disability, but it has. I’m hopeful I will find a solution that will help me to live my life the way I used to again soon. I can not express enough gratitude for my surgeon who has been tirelessly providing help to solve this. every step of the way.

I hope this update was of interest. If you have any opinions or comments, I would welcome them.
Well you are at an excellent institution Mass E&E.  A few comments. Pilocarpine can increase the risk of retinal detachment, cause inflammation within the eye and with prolonged used prevent the pupil from dilating even with drops.  I never use the drops. If you are on Pilo it should be a very low concentration 0.5% or 1% at most.  There is another drop that sometimes helps with dilated pupil especially at night,   LINK:  https://www.nature.com/articles/s41598-018-27436-8   you might ask for a trial for this.  Gas Perm CTL will help with irregular corneal astigmatism but not lenticular astigmatism.  I don't really have anything further to officer or suggest. Except that vitrectomy whether done for floater only or an eye full of blood has been associated with permanent double vision after surgery.
233488 tn?1310693103
First of all "simple vitrectomy' is an oxymoron.  There is no such animal.  A vitrectomy is a major operation, always.  Furthermore I hope you understand it is very likely that eye will develop a cataract sooner than later, as that is a well known risk of vitrectomy.

Your OCT is normal and I agree with Mass EE that this is a refractive issue.   Your eye muscles strain is likely that you are having presbyopia symptoms at age 44.  I suggest you get a pair of glasses with your full correction i both eyes including astigmatism in both eyes and a reading add appropriate to your age (about +1.50) and get used to progressive/no line bifocals. Takes most people about a week or two.  I suspect your eyes will look see and feel much better and the Amsler look better. Your uncorrected astigmatism can cause distortion on the Amsler.   Any cloud, or 'moving' distortion is likely vitreous debris as vitrectomy usually not remove all vitreous floaters.

I think you team has identified the problem, refractive and your presbyopia and uncorrected astigmatism.
Helpful - 0
Hi Dr. Hagan, thank you for your response. I appreciate you looking at my OCT scan as well. May I please follow up with clarifying concerns?

1. I did not feel the disequilibrium wearing my contacts before the surgery, even with pushing the envelope reading-wise and holding my iphone the usual arm’s length away for clarity. I’ve been cheating the need for readers for a good year now and can’t say I’ve ever felt these sensations. This dizziness is new and strange, and seems to emanate from the operated eye. Despite the clear acuity, it feels like I’m looking through antique window glass or water. Again, it doesn’t look that way, but feels it. I’m sorry for the limited description, I have no better language with which to explain. I just wanted to clarify because I’m very frightened my eye is somehow broken and this feeling is permanent.

2. The astigmatism at -75 is only in my left operated eye. My contacts do not correct for it (soft Acuvue2) but the eyeglasses do. I frankly never knew I had astigmatism, until I located my eyeglasses prescription recently. It has never caused distortions like this before. I don’t have astigmatism in my right eye.

3. The surgeon said, “Honestly, I wouldn’t expect what I’m seeing in your lens to cause the symptoms you’re describing, it’s so trace, but I suppose it could possibly be scattering the light a bit.” If this is the case can it be corrected with a new prescription?

4. The “blip” in horizontal lines is, to my best knowledge, not a floater. It’s repeatable in the same position and behavior. House siding, horizontal lines on the computer, anything very distinctly linear will cause this “blip” or “jump” in the center of the line. It does move down the line, but it seems optical as opposed to “floater.” I just wanted to offer this in case it changed your mind about something. Floater wise, my eye is crystal clear.

I apologize if I’m redundant. I felt the need to reiterate I experienced none of this before the surgery. I am scared I am a zebra.

I am grateful for your time and interest.

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